SWOT analysis of the models used by social enterprises in scaling effective refractive error coverage to achieve the 2030 in SIGHT in Kenya

Uncorrected refractive error has predominantly been delivered through commercial entrepreneurship in Kenya. However, to achieve the 2030 IN SIGHT, integration of other forms of entrepreneurship such as the social entrepreneurship is desirable to supplement the efforts of the dominant commercial entrepreneurship. Therefore, this study intended to undertake a SWOT analysis of the current models used by social enterprises in scaling effective refractive error coverage to achieve the 2030 IN SIGHT in Kenya. A review of the seven national strategic plans for eye health in Kenya was undertaken to get a glimpse on the efforts directed towards uncorrected refractive error in achieving the 2030 IN SIGHT. The review was inclined towards assessing the efforts directed by the strategic plans towards scaling human resource, spectacle provision and refraction points. A SWOT analysis was undertaken based on the financial, impact and the approach report for each model. A key informant interview was conducted with a representative and three to five members of the social enterprise about the model. Thereafter, the modified SWOT analysis based on the review and the interview was presented to the representatives of the social enterprises. Purposive sampling was used to identify seven models used by social enterprises in the delivery of refractive error services in Kenya. Finally, the recommendations were presented to key opinion leaders for an input through a Delphi technique. Out of the seven national strategic plans for eye health reviewed, only the strategic plan 2020–2025 intends to establish optical units within 15 different counties in Kenya. Of the seven models currently utilized by social enterprises, only the Kenya Society for the Blind has integrated the telemedicine concept. On application of mHealth, all of the social enterprises models tend to embrace the approach for screening activities. None of the models has a strengthened referral pathway utilizing telereferral and telemedicine. Out of all the models, only Operation Eyesight Universal, Fred Hollow Foundation and Peek Acuity do not depend on sales of subsidized spectacles for sustainability. Every model has the capacity to propel the delivery of refractive error services depending on its comprehensiveness. However, for the 2030 IN SIGHT to be achieved, models prioritizing human resource through telemedicine integration, service provision across all sectors, awareness creation and enhancing cost efficiency are desirable.

Uncorrected refractive error (URE) is the presenting visual acuity of less than 6/12 in the better eye with an improvement of at least two lines after refraction 1 .According to the Global Burden of Disease 2020, 338.8 million people globally had moderate and severe visual impairment (MSVI) with a projection of 535 million by 2050 if no interventions are taken to reduce avoidable blindness 2 .The 2030 in SIGHT demands that by 2030, no-one should experiences unnecessary or preventable sight loss and eye care and rehabilitation services should be accessible, inclusive and affordable to everyone, everywhere, whenever they are needed 3 .A study by Jung 4 showed that a significant unmet healthcare needs have been observed among poor people living in remote areas.However, a social enterprise (SE) which is an organization which participates in business ventures through a commercial approach in order to fulfill a social purpose 5 , could potentially enhance the health and wellbeing of vulnerable groups through provision of affordable healthcare products and services 6 .Notwithstanding, social enterprises (SEs) have been shown to engage in various programs including provision of cost effective services and products to population more likely to suffer from health inequalities 7,8 .Even though in Kenya the commercial enterprises which majorly prioritize profit generation dominates the optical industry 9 , warranting the need for evaluating the contributions of different sectors including the SEs towards achieving the 2030 in SIGHT.Therefore, this study intended to assess the strength, weaknesses, opportunities and threats (SWOT) of the current models used by SEs, in scaling effective RE coverage.
While, since the late 1990s, the concept of social entrepreneurship has been used in different countries all over the world as a viable tool in delivering social goals, developing policies to recognize social entrepreneurship as a means of providing public services to meet the changing needs in a society is still lacking 10 .The existence of SE has been attributed to the market failure and a social value for the public good 11 .Social enterprises tend to bridge human resource gap in the eye health ecosystem in developing countries in Kenya through approaches such as skills development 12 .While in Kenya, conventional training of human resource supersede skills development, limited resources hinders the government from training enough eye care professionals to attend to the growing population.However, with approximately 15.5% of the Kenyan population being in need of eye care services 13 , cost effective approaches such as the skills development undertaken by SEs could be integrated within the existing workforce.With emergence of innovative approaches such as telemedicine which is the provision of health care remotely via information and communications technology 14 , integration is desirable within the existing models used by SEs.Based on socioeconomic perspective, telemedicine has contributed to providing healthcare to previously underserved regions with provision of care which was not previously deliverable 15 .With the minimal information on the innovative components utilized by different SEs models, this study intended to identify what makes SEs models unique and ideal in scaling effective RE coverage.
The increased interest in SEs is as a result of the role they play in addressing unresolved social problems on an international scale while enhancing human development around the world and improving quality of life 16 .This implies that the involvement of SEs in improving health and wellbeing represent a shift on the potential role for business in promoting health beyond profit 17 .Although SEs experiences challenges around sustainability just like any other business, the innovative nature makes SEs to thrive.Social enterprises have been shown to respond to societal challenges through social innovation and making sure that the solution is accessible based on a viable business attention 6 .However, minimal information exists on how the existing SEs models in Kenya enhance sustainability.In Scotland, SEs have been shown to improve health outcomes through direct delivery of primary healthcare and community development program addressing such vulnerabilities 18 .Even though aspects around community engagement, legal compliance, accessibility, affordability, acceptability and the quality of services delivered by SEs remains unknown in Kenya, such information is desirable.In developed countries such as United Kingdom, there exist specific legal entities for SEs which encourages SEs to form frameworks 12 .Therefore, this study intended to evaluate the current models used by SEs with an aim of providing recommendations inclined towards scaling effective refractive error (RE) coverage in Kenya.

Materials and methods
This study was conducted in two phases.The first phase entailed a scoping review of the seven national eye health strategic plans for eye health in Kenya 13, 19 .The review was anchored on aspects around human resources; refraction points/vision centres, refractive error and spectacles provision.Google Scholar was the main search engines used to extract information regarding the existing national strategic plans for eye health in Kenya.Additional information was retrieved from the Ministry of Health website and policy documents on eye health in Kenya.A Boolean operator of "AND" and "OR" was used.The keywords used were as follows: vision centres OR refractive error OR eye health OR refraction OR national strategic plan AND Kenya.This review was intended to understand the government of Kenya efforts towards addressing URE and the recommendations in the strategic plans.The seven national strategic plans for eye health review were downloaded and thereafter reviewed systematically with a focus on the recommendations on addressing URE from the first strategic plan and the achievements in the subsequent strategic plan.The intention of the review was to provide a justification for the need of a specific strategic plan for URE in Kenya.The proposed strategic plan for URE was presented to representatives from SEs and key opinion leaders for their input.
Seven SEs delivering RE services in Kenya were purposively identified.The SEs included the Dot glasses, Operation Eyesight Universal, Fred Hollow Foundation, Eye Rafiki, Peek Acuity, The Kenya Society for the Blind and VisionSpring.The rationale for choosing the seven SE was based on their distinct models replicated in different parts of the world to deliver RE services.The contact details for the SEs were retrieved from their official websites.The SEs were contacted through emails and telephonic calls with an overview of what the study was about.The SEs were asked to endorse a representative with understanding on the model used to participate in the study.The condition for one to be included as a representative to participate in the study, one ought to have engaged in the implementation of a RE program within the SE.The models used by the SE were explored through a telephonic interview with representatives provided by the SEs.The interviews entailed an inquiry of the approaches they are applying in the delivery of RE services, quality and cost of care, acceptability, accessibility, affordability of their products to the base of pyramid population, community engagement and the challenges experienced with the delivery approaches including sustainability.The samples of questions used to seek information from representatives of SEs about the model are shown in Table 1.
During phase two, a SWOT analysis was undertaken to assess the internal and external factors for each model.A review of the existing documents such as the financial reports, impact reports and reports around the approach was undertaken.PubMed and Google Scholar were the main search engines used to extract information regarding the financial reports, impact reports and reports around the approaches used by the seven SEs in Kenya.Additional information was retrieved from the SEs websites.A Boolean operator of "AND" and "OR" was used.The keywords used were as follows: financial report OR model approach OR refractive error OR impact report OR SEs AND Kenya.The rationale for the review was to obtain an objective SWOT of the models given that most organizations may not provide the weaknesses of their approaches to an external researcher.The second step entailed an online key informant interview with three to five members of each SE.The key informant interview comprised of open ended questions adopted from a study by Zoschke et al. 20 as shown in Table 2.After the key informant interview with all the seven SEs, the responses were crosschecked with the SWOT analysis from the review.Additional information retrieved from the key informant interviews was included in the SWOT analysis from the review.Thereafter, the final SWOT analysis was presented to the three to five representatives from SEs for their view on the relevancy of the proposed components within the existing models.
Finally, the proposed aspect to be integrated into the existing models used by SEs was presented to ten key opinion leaders through a Delphi technique.The rationale was to get the broader picture of whether the proposed revisions within the existing models would impact on effective RE coverage and the 2030 IN SIGHT in Kenya.The conditions for inclusion as a key opinion leader was that one had to have been involved in the social entrepreneurship and clinical experience on RE, advocating for the relevance of the concept of social entrepreneurship integration into the eye health ecosystem in Kenya and influence on policies around the eye health in Kenya.The key opinion leaders comprised of an administrator in-charge of eye care services at the ophthalmic service unit Kenya, an ophthalmologist representing the ophthalmological society of Kenya, an optometrist representing the optometrists association of Kenya, an Information and Communication Technology expert from an international SE, an optometrist in-charge of training of the optical technicians, a policy expert representative from the Kenya

Delphi rounds, data collection and analysis
A systematic and meaningful synthesis of responses was ensured through drafting and refining the questions asked of the key opinion leaders in every round.The questionnaire was piloted among members of our authorship team who were not directly involved in designing the Delphi.We communicated with the key opinion leaders in English and used Google Forms to conduct our surveys.
A pre-specified definition of consensus was developed based on two criteria 23 .First, the key opinion leader was eligible to have achieved consensus around a given survey item if at least 70% of respondents agreed with that item.When using a five-point Likert scale, we defined "disagreement" as a score of two or less.This criterion ensured that a strong majority of respondents agreed with any included survey item.Second, an item was said to have achieved consensus only if none of the dissenting respondents raised concerns that were fundamentally incompatible with the inclusion of that survey item.
This criterion aligns with approaches from formal consensus decision-making, where a structured discussion is used to understand and resolve the merits and drawbacks of a given proposal 24 .This approach recognizes that essential insights can be tendered by a minority of decision-makers, and attends to the substance of minority opinions.Procedurally, these minority opinions were gathered by requiring that key opinion leaders offer freetext comments if they disapproved of a survey item.We analysed these free-text responses and incorporated that feedback into subsequent rounds of the Delphi and into the final task shifting framework.As the analysis advanced, an emphasis on and reiteration of certain issues above others became more apparent.These elements coalesced into the final categories and themes.
Round I was designed to elicit broad and general concepts from the key opinion leaders using unstructured, open-ended, questions: 1. What is, in your opinion, the potential of the proposed approaches for integration into the existing SEs models and effective RE coverage?
2. What are the three to five characteristics of refractive error that make it amenable to modification of the current models used by SEs in Kenya?
3. What are three to five examples of activities that the Ministry of Health could undertake to ensure success of the SEs models?
Following Round I, the researchers combined and analysed the key opinion leader's responses in taxonomy according to common themes and categories.We attempted to make the items on each list mutually exclusive and comprehensive.We synthesized these findings in a survey to elicit participants' level of agreement with each of the themes and categories on a five-point Likert scale for Round II.This survey also offered free-text response options for key opinion leaders to add additional comments or categories as required.
Once we received all responses from Round II, these data were again reviewed by the researchers.Concepts were eliminated and retained on the basis of the key opinion leader's scores and collapsed into more general categories, including a definition of task shifting and telemedicine, the purpose of task shifting ad telemedicine, opportunities arising from task shifting and telemedicine programmes, and conditions required for the implementation of task shifting and telemedicine.These results were sent back to the key opinion leaders as a survey for Round III.Key opinion leaders were asked to review the final list of items, state whether they agreed or disagreed with each item, and voice concerns or comments in free text.Following Round III, the researchers integrated the experts' consensus responses into a reasonable and manageable set of concepts and sub-concepts to form the framework 23 .
The statistical data analysis for quantitative data was conducted in the Statistical Package for the Social Sciences version 29.0.0,2022.The quantitative data was analysed through descriptive statistics of frequencies and percentages.The qualitative data was analyzed thematically using NVivo Software, Version 11.Thematic analysis was carried out by categorizing the codes into categories using NVivo Software, Version 11 and themes based on the semantic meaning of the codes.It was an iterative process consisting of both deductive and inductive processes 25 .Initial codes and categories were generated from the interview guides (deductive process).New www.nature.com/scientificreports/categories that consist of similar codes were added as required to capture the participants' comments in details (inductive process).During this inductive process, the themes were identified by repetitions (the more the concept appears in the text, the more likely it is to be a theme), similarities and differences 26 .

Ethics approval and consent to participate
This study was performed in accordance with the Declaration of Helsinki, and has been approved by the Biomedical Research Ethics Committee (BREC/00004105/2022) and Maseno University Ethics Review Committee (MUERC/1051/22).Informed consent to participate in the study was obtained from all participants.

Demographics of the participants
All of the representatives from the seven SEs whose models were included in this review, responded to the interview.The representatives constituted (n = 4; 57%) females and (n = 3; 43%) males.The key opinion leaders comprised of (n = 4; 40%) females and (n = 6; 60%) males.

Review of the national strategic plans for uncorrected refractive error in Kenya and recommendations
According to the Kenya Ministry of Health 13 , an estimated 15.5% of Kenyans are in need of eye care services.As a result, seven National Eye Health Strategic Plans have been developed with different themes to address eye health in Kenya.However, a critical review of the strategic plans denoted that minimal attention has been directed towards addressing URE in Kenya.For instance, only the national strategic plans for the periods 2012-2018 and 2020-2025 provide recommendations on URE, while the other five national strategic plans only define URE and denote that the prevalence URE remains unknown in Kenya.Notwithstanding, the strategic plans like that for the period 2012-2018 19 denoted the importance of training human resource to undertake refraction and the establishment of optical units at secondary and tertiary levels.However, as at 2018, the evaluation report showed that the majority of the public eye units were not well equipped with most units having only slit lamps and ophthalmoscopes but lacking retinoscopes and trial boxes 13 .This is a clear indication that URE receives minimal attention in the public health sector.In the review of the national eye health strategic plan 2020-2025, an intention to establish optical units in 15 counties has been proposed within the strategic plan.However, the plan does not show how they will cost effectively scale human resource to be deployed in the suggested optical units.Therefore, with the burden of URE, a national strategic plan for addressing URE was proposed as shown in Fig. 1.
All of the key opinion leaders (100%) agreed that the proposed approach is relevant in addressing URE since minimal attention has been directed towards URE in Kenya.The key opinion leaders argued that designing a specific URE strategic plan will motivate the government to act and allocate resources towards addressing URE (quotes 1-2).
1.I will say that with lack of population based studies, minimal attention has been directed towards addressing refractive error, as a result, I think adopting this specific framework more inclined towards addressing refractive error will ensure that attention is directed towards addressing this challenge-Opinion leader#03 2. This framework can really work given that the budget allocation towards addressing uncorrected refractive error is absent in most counties, hence if this approach is adopted then the small allocation will scale service delivery in Kenya-Opinion leader#07 All of the key opinion leaders agreed that the proposed strategic plan for addressing URE in Kenya is ideal as it intends to address the human resource and infrastructure challenges.The key opinion leaders denoted that advocating for scaling refractive error services within the public health sector is crucial as it scales availability (quote 3-4).
3. In my own view I' d like to say that coming up with this plan which targets human resource is worth as scaling services without considering human resource may produce minimal impact-Opinion leader#03 4. Talking about telemedicine and a strengthened referral pathway is crucial for refractive error service delivery and if the public health sector can result to a scaled refractive error service delivery-Opinion leader#06 All of the SEs representatives reported that the proposed national strategic plan for URE is suitable but the task force committee should include different sectors (quote 5).
5. I will confidently say that we need something of this sort more specific towards addressing uncorrected refractive error in Kenya.however, the taskforce committee should constitute individuals from different sectors with partnership being key-Social enterprise representative#02

Phase two
A SWOT analysis of the current models Eye Rafiki model.Table 3 and 4 details the SWOT analysis of the Eye Rafiki model.
The representative from the Eye Rafiki and the team members reported that the SWOT analysis provides the actual situation they are in and agreed that the opportunities are ideal (quote 6).
6.The weaknesses identified from this SWOT analysis are things we experience and we anticipate that implementation of the opportunities identified is worthy-Representative from Eye Rafiki Based on the input from the Eye Rafiki representatives, stages for integrating skills development in existing training institutions offering eye health programs was proposed as shown in Fig. 2.
A quarter of the key opinion leaders (n = 7; 70%), agreed that the proposed approach for the integration of skills development into existing training institutions offering eye health programs is a good approach and should be adopted.The key opinion leaders denoted that this approach has the potential to scale human resource in a cost effective way.They also argued that prioritizing telemedicine utilization will scale effective RE coverage in Kenya (quotes 7-8).
7. The interesting part of this proposed approach is that it intends to scale human resource in eye health which I think will scale refractive error service delivery in a cost effective way-Opinion leader#03 8.In Kenya, the eye health sector hasn't prioritized primary vision technicians but I think if this approach is adopted then service delivery will be scaled as telemedicine is also prioritized-Opinion leader#06 All of the key opinion leaders (100%) agreed that the holistic approach is relevant within the Kenyan context as it remains cost effective when compared to the conventional approach.The opinion leaders denoted that an approach where primary vision technicians can receive support from optometrists through telemedicine can enhance quality service delivery (quotes 9-10).9. We always have problems with primary vision technicians as we question their quality when it comes to refractive error service deliver, but if they can be supervised by qualified eye care professionals like optometrists through telemedicine then it's a good approach-Opinion leader#05 www.nature.com/scientificreports/10.I think telling primary vision technicians to come back for upgrading is a good think but because resources are limited, it will not be cost effective-Opinion leader#01 All of the key opinion leaders (100%) agreed that the clinical exposure approach is relevant and should be prioritized for quality RE service delivery.The key opinion leaders argued that it will relevant if the primary vision technicians can be integrated into the primary level public and private sectors.However, they stated that it may a long term approach as currently cadres such as optometrists remain outside the public service in Kenya (quotes 11-12).
11. It's interesting to come across this suggestion of clinical exposure for primary vision technicians as currently the reason as to why many primary vision technicians in Kenya find it hard to operate smoothly is because of questions about the quality they can deliver-Opinion leader#04  www.nature.com/scientificreports/12.I will say it will be hard to prioritize primary vision technicians in Kenya given that even optometrists remain outside the public service and they play a crucial role in addressing refractive error.Therefore, it is a good suggestion but it may take longer to be implemented hence the telemedicine suggestion is ideal-Opinion leader#02 The Kenya Society for the Blind Model The representative from the Kenya Society for the Blind (KSB) and the team members reported that the SWOT analysis provides an insight on applicable opportunities that should be explored (quote 13).
13. Always doing a SWOT analysis provides solutions that could be adopted.I will say that the opportunities suggested such as engaging individuals from the private sector in managing the vision centres at the public hospitals is something that should be adopted-KSB representative Based on the input from the KSB representatives, a proposed vision centre approach was developed as shown in Fig. 3.
Half of the key opinion leaders (n = 5; 50%) agreed that this proposed vision centre approach is appropriate and can scale effective refractive error coverage.The key opinion leaders argued that this proposed approach is inclusive and addresses aspects around human resource and service delivery in a cost effective way (quote 12).www.nature.com/scientificreports/However, just under three quarters of the opinion leaders (n = 7; 70%) were neutral about the aspect of contracting the private sector to run the vision centres integrated within the public hospital sectors (quote 14).
14.In an overview of this approach, I think it can scale refractive error service delivery cost effectively given that it plans on how to scale human resource and bring in the telemedicine concept at the same time-Opinion leader#05 15.I agree the public sector has challenges which the private sectors can address, however, if we bring the private sectors then we must ensure that spectacle rates are standardized as private sector rates always remain higher and they should not bring the same trend if they are contracted to do management-Opinion leader#03 All of the key opinion leaders (100%) agreed that training of middle level healthcare professionals is a good initiative and should be prioritized (quote 16).They argued that the aspect of integrating existing primary vision technicians such as the Eye Rafikis who are already trained will be more cost effective and should be considered (quote17).16.In most situations, it will be good if the middle level healthcare professionals can be trained on the basics of refraction because we do have limited human resource and the supervision aspect through telemedicine makes it much better and realistic-Opinion leader#06 17.I agree with the suggestion of integrating the already trained personnel's as it will not only be cost effective and speeds up the achievement of the 2030 IN SIGHT agenda but it will enhance sustainability-Opinion leader#01

Peek acuity
Table 7 and 8 details the SWOT analysis of the Peek Acuity.
The representative from the Peek Acuity and the team members reported that the SWOT analysis provides an insight on applicable opportunities that should be explored (quote 18).
18.The proposal for the modification of the application is holistic and I believe if such is undertaken then the application will not only address screening but will also enhance awareness to the general population and hospital visits-Peek Acuity representative All of the key opinion leaders (100%) agreed that the suggestion of modifying the Peek acuity chart for utilization by everyone to self-assess will enhance awareness in a more convenient way (quote 19).The key opinion leaders denoted that if such modification can be undertaken then more RE patients will visit eye hospitals for refraction.The hub and spoke model Table 9 and 10 details the SWOT analysis of the hub and spoke model.The representative from the VisionSpring and the team members reported that the SWOT analysis provided was timely and identified the weaknesses of the model and possible solutions that could be adopted (quote 20).20.This analysis provides possible solutions that could be adopted to scale refractive error services to achieve the 2030 in SIGHT in Kenya-VisionSpring representative Given the challenge around recruitment of community members for skills development denoted within the Eye Rafiki model and the hub and spoke model, an assessment guideline was developed for competitive recruitment as shown in Table 11.
All of the key opinion leaders (100%) agreed that using this assessment approach to identify community members for training will ensure that right candidates are trained.The key opinion leaders argued that using this approach will instill a sense among interested community members that there is a burden called refractive error that they are destined to work towards addressing (quote 21).
21.For me I will say one of the challenges we have is recruitment of community members tasked with provision of refractive error services in Kenya.As a result I think using something like the suggested will  All of the key opinion leaders (100%) agreed that the human resource remains a major challenge in the eye health ecosystem in Kenya and a structured approach should be designed to ensure that anyone trained have the potential to deliver RE services contributes towards enhancing effective RE coverage (quotes 22).
22. Mostly it is hard for the trained community members to deliver refractive error services effectively since what they do remains unknown among other eye care professionals hence through a structured approach, all the trained personnel's can be distributed to scale effective refractive error-Opinion leader#01 Addressing the weak referral pathway was proposed as shown in Fig. 4. All of the key opinion leaders (100%) agreed that the proposed referral approach is appropriate as it integrate the concept of telemedicine and gives the primary vision technicians a role to play within the referral pathway.
The key opinion leaders argued that this referral approach is inclusive of all players within the eye health ecosystem (quotes 23-24).
23. Telemedicine would be a more suitable tool in addressing refractive error in Kenya given that the human resource remains limited and most optical shops are in urban areas-Opinion leader#03   www.nature.com/scientificreports/24.I only have to say that this approach will ensure quality refractive error service delivery and a more holistic approach in addressing refractive error since cases beyond the scope of any cadre will be referred easily-Opinion leader#07

Operation eyesight universal model
Table 12 and 13 details the SWOT analysis of the Operation Eyesight Universal model.The representative from the Operation Eyesight Universal and the members reported that the proposed opportunities could potentially scale RE services if adopted (quote 25).
25. Always generating income for sustainability of the model is key as we fulfill our social mission.Hence the proposed opportunities are desirable and the weaknesses should be addressed-Operation Eyesight Universal representative All of the key opinion leaders (100%) agreed that the aspect of training the teachers to do vision screening for pupils is an important aspect as it will ensure quality of life and academic performance among the pupils.They argued that integrating telemedicine will ensure that the trained teachers manage RE appropriately and refer cases beyond their scope (quotes 26-27).26.Training teachers to undertake vision screening is a cost effective way that will ensure that refractive error status for pupils is diagnosed early allowing effective refractive error management-Opinion leader#05 27.I agree with the telemedicine integration because it will ensure quality delivery given that the teachers are given basic training and if they are supervised through telemedicine then the 2030 IN SIGHT will be achieved-Opinion leader#08

Fred hollows foundation approach
Table 14 and 15 details the SWOT analysis of the Fred hollows foundation approach.
The representative from the Fred Hollows Foundation (FHF) reported that advocating for integration of subsidized spectacles within the public health sector is desirable (quote 28).
28. Since correction of RE simply require a simple pair of spectacles, the suggestion of integrating subsidized spectacles within the public health sectors is worthy of attention-FHF representative All of the key opinion leaders (100%) agreed that equipping community health volunteers with screening tools like the PA mobile acuity will scale vision screening and effective RE coverage.They argued that integrating the optical aspects in the government health facilities is relevant (quotes 29).31.Clearly if this proposed approach can be utilized then it will ensure the cases seen at Dot Glasses who require prescription spectacles can be sent to the KSB model for dispensing-Opinion leader#10 All of the key opinion leaders (100%) agreed that integrating telemedicine an embracing a skills development for primary vision technicians is worthy of attention.The opinion leaders denoted that the efforts directed toward scaling human resource in eye health is crucial and the aspect of supervising their activities through telemedicine will make the primary vision technicians more relevant in the eye health ecosystem (quotes 32-33).
32.One of the most critical suggestion with this approach is that it will make the primary vision technicians more useful in the delivery of refractive error services given that they will be getting supervision from qualified eye care professionals like optometrists-Opinion leader#03 33.I agree with the suggestion on telemedicine integration and the mHealth applications because it will ensure that the primary vision technicians can carry screening activities effectively through the Mhealth applications and get supervision through telemedicine-Opinion leader#07

Discussion
The current national strategic plan for eye health in Kenya 13 incorporates RE in its plan but has not shown how they intend to achieve the targets holistically given the limited resources available.This could be attributed to the fact that the prevalence of URE in Kenya from population based studies remains unknown 27 resulting in minimal efforts directed towards addressing URE.As a result, this review denotes the need for establishment of a national strategic plan inclined towards addressing URE as shown in Fig. 1 to act a guideline for the current models used by SEs in Kenya.However, for such national strategic plans to be established, optometrists in partnership with all stakeholders in eye health should be at the forefront in undertaking population based studies to showcase to the government the need for prioritization of URE.With the devolved system of governance in Kenya 28 , addressing URE may only be achieved if each devolved unit direct efforts towards addressing URE.Hence it is anticipated that the proposed strategic plan may facilitate a balanced establishment of refraction points and distribution of human resource in different geographical locations as opposed to the current situation where most optical units are located within urban areas 27 .Notwithstanding, it is also anticipated that establishing a strategic plan will ensure that RE indicators are integrated within the hospital information system for easy tracking through a quality assurance team.Therefore, the current models used by SEs should engage in research and periodically collect and report on effective RE coverage so as to achieve the 2030 in SIGHT.
Human resource remains a major challenge in the eye health ecosystem in most developing countries such as Kenya 27 .Being that human resource is a critical aspect necessary for the achievement of the 2030 IN SIGHT, the conventional training approach needs to be supplemented with other cost effective approaches.This SWOT analysis has showed that only the KSB model does not undertake skills development.This could be attributed to the fact that the KSB is a state corporation hence not dynamic when compared to other SEs.This study has also showed that some SEs such as the Peek Acuity, KSB and Operation Eyesight Universal have embraced technology integration into their activities.Given that access to RE services has been a major challenge among the underserved population, evidence shows that application of telehealth in primary eye care reduces logistical barriers faced by vulnerable patients 29 .According to the World Health Organization, four out of five developing nations now offer at least one type of mobile health program to deliver essential health services to the population 30 .A meeting abstract by Mair and Whitten 31 , examining telemedicine delivered subjective refraction found no statistically significant difference between in-person and telemedicine delivered subjective refraction.Therefore, to achieve the 2030 in SIGHT in Kenya, the existing SEs models should embrace integration of technology such as telemedicine so as to strengthen trained individuals through skills development and ensure quality RE service delivery.
Social enterprises attempts to address social needs not addressed by the government and or the commercial enterprise sector 6 .In Kenya, most eye care professionals operate from urban areas as most optical units are situated in urban areas hence limiting the underserved from rural areas from accessing RE services 27 .A World Bank, survey revealed that social enterprises depend mostly on donations and subsidy of services for sustainability 32 .However, to achieve the 2030 in SIGHT in Kenya, sustainability of the models should be prioritized.This study www.nature.com/scientificreports/result has showed that apart from the FHF, Operation Eyesight Universal and Peek Acuity, all the other SEs models apply approaches such as sales of subsidized spectacles to ensure sustainability.This is contrary to the LV Prasad Eye institute which declined donor funding and funds from other organizations with repayment terms and conditions 33 .Given that SEs addresses inequality more broadly by acting on the social, economic and environmental circumstances of the most vulnerable members of the society, factors such as financial constraints and policy regulations influences sustainability 34 .This study has identified policy regulation and conflict of interest among eye care professionals and individuals trained by SEs which influence their sustainability.Therefore, a suitable ecosystem should be provided for SEs to ensure an efficient delivery of RE services.
Being that approximately 90% of the populations in developing countries are in need of RE services [35][36][37] , awareness creation is a key important aspect desirable for the achievement of the 2030 IN SIGHT.This study has shown that some models are enhancing awareness creation on RE in Kenya.This could be attributed to the current situation in which the awareness around RE services has received minimal attention by the government hence SEs work towards bridging this gap.Although awareness creation among the general population is an important aspects 38 , the population at the base of economic pyramid may not seek the services if awareness is not enhanced.Again this study has showed that community engagement is a key aspect considered by some SEs models currently delivering RE services in Kenya.Evidence shows that almost half of the world population will suffer from myopia by 2050 warranting the need for a strengthened community engagement to curb the burden 39 .As a result, strengthening awareness creation and community engagement is desirable to enhance achievement of the 2030 IN SIGHT.
Accessibility, availability and affordability remain the key barriers influencing RE service delivery in Sub-Saharan Africa 40 .As a result, the public sectors are trying to address the barriers around accessibility, availability and affordability of RE services.However, given the limited resources available in developing countries 27 , other stakeholders in eye health such as the SE are trying to supplement the efforts of the public sectors by deploying cost effective models targeting the population across the economic pyramid so as to achieve the 2030 IN SIGHT.The current study findings acknowledge that with some models, SE in Kenya are establishing refraction points with cost effective spectacles within rural areas to enhance accessibility, availability and affordability.This initiative if acknowledged and supported by the government has the potential to propel the achievement of the 2030 IN SIGHT in Kenya since continuity in RE service delivery demands sustainable financing approaches.Non-affordability and poor accessibility of the services among rural areas are identified as an important indication for the high prevalence of blindness 41 .However, given that RE services are not available in many public health sectors in Kenya 27 , the models used by SE should advocate for a partnership with the public health sector so that they can introduce RE services within the public health sector and adopt a team approach to aid in the achievement of the 2030 IN SIGHT in Kenya.
Most SEs have proven to be innovative as per the models they are using to deliver URE in Kenya across the economic pyramid in Kenya.However, a review of the current models used by SE in Kenya suggests that they can only achieve the 2030 IN SIGHT if a strong partnership is enhanced amongst them.The findings of this study has also noted that the current models used by SE in Kenya remains weak in terms of referral and replication of concepts amongst the social enterprises.The weak referral could be attributed to absence of a strengthened relationship between the SE and the public sectors.Although the social entrepreneurship concept is taking shape in Kenya 42 , existing SE face challenges which limit their full potential when it comes to RE service delivery.As a result, the government should provide a supportive environment for SE so as to undertake activities leading to achievement of the 2030 IN SIGHT agenda in Kenya.A team approach and partnership is worthy of attention across all sectors in eye health so as to facilitate the 2030 IN SIGHT achievement in Kenya.Therefore, with some models of SE in Kenya utilizing technology such as the Peek Acuity 43 , replication of some concepts is desirable to scale RE service delivery and achieve 2030 IN SIGHT agenda.
In conclusion, with the dynamic nature of the models used by SE, they are well placed to propel the achievement of the 2030 IN SIGHT in Kenya.Therefore, to achieve the 2030 in SIGHT in Kenya, the current models used by SE in Kenya should explore the proposed opportunities from the SWOT analysis.Some of the key opportunities that should be prioritized include integration of telemedicine, community engagement, awareness creation, advocacy towards policy changes and sustainability. https://doi.org/10.1038/s41598-024-54493-z

Figure 1 .
Figure 1.Proposed national strategic plan for uncorrected refractive error in Kenya.

Figure 2 .
Figure 2. Proposed stages for integrating skills development in existing training institutions offering eye health programs.

•
Scale to comprehensive refraction for all types of refractive errors • Not cost effective as the trained individuals have to move from one area to the other • Integrate telereferral to allow trained community members to refer patients for comprehensive examination • Policy regulations • Integrate telemedicine to allow for supervision of the trained individuals • Establish strategic vision centres based on population studies to allow for comprehensive refraction • Target everyone across the economic pyramid • Avail reading glasses in public and private healthcare facilities and engage in scaling awareness among the general public on the availability of the services in such facilities • Link the model with other existing models such as the KSB which undertakes comprehensive RE services Vol:.(1234567890)Scientific Reports | (2024) 14:3750 | https://doi.org/10.1038/s41598-024-54493-zwww.nature.com/scientificreports/ensure we get right candidates and the process remain competitive hence creation of commitment by the trained individuals-Opinion leader#07

1 .
What is the motivation behind your application for this refraction training?2. Are you able to raise some finance to start a refraction point in a local setup?3. Do you think it is possible to do business with the underserved population? 4. If yes to the above, how do you plan to raise the capital? 5.If in case you succeed to raise capital and establish a refraction point, what are some of the mechanisms you will use to influence the local population to seek your services?6. Are you able to work as a team in case you set up a refraction point with another person who resides in your neighboring sub-location?7. If yes to the above, which mechanisms will you apply to ensure that you work smoothly?8.If you establish a refraction point and you realize that patients are not showing up and paying rent becomes a problem, what will you do? 9.If in case you establish a refraction point, will you work with other sectors providing similar services as yours?

Table 1 .
Sample of questions presented to representatives of social enterprises and the key targeted indicators.

Table 2 .
The SWOT analysis questions.

Table 3 .
Strength and weaknesses of the eye Rafiki model.Identify community members and training them on the basics of refraction Lack of a structured approach in recruiting community members for skills development Engaging the Ministry of Health to establish the scope of practice for individuals with skills development The established scope of practise by the Ministry of Health limits the trainees from conducting refraction hence contradicting the training being undertaken Advocated for recognition of the training by the Technical Vocational Education and Training in Kenya Lack of a structured certification of the trainees Generating income from sales of glasses at the vision centres and during vision screening events Lack of a remote supervision for the trainees Sustainability Lack of innovative approaches to scale services and enhance awareness on their existence in the remote areas Lack of a partnership between the trainees and established optical units Weak referral pathway

Table 4 .
Opportunities and threats of the eye Rafiki model.

Table 5
and 6 details the SWOT analysis of the Kenya Society for the Blind Model.

Table 5 .
Strengths and weaknesses of the Kenya Society for the Blind Model.

Table 6 .
Opportunities and threats of the Kenya Society for the Blind Model.
Opportunities ThreatsEngage the private sector to run the vision centres located within the public sectors Professional discordance Integrate the vision centres across the Public and private sectors Lack of policies around importation of RE services such as spectacles Prioritize reporting of URE cases from community vision screening activities Scale services to remote areas Figure 3. Proposed vision centre approach.Vol:.(1234567890)Scientific Reports | (2024) 14:3750 | https://doi.org/10.1038/s41598-024-54493-z

Table 7 .
Strengths and weaknesses of the peek acuity.

Table 8 .
Opportunities and threats of the peek acuity.19.I can say this suggestion is more relevant since the big problem we do have is awareness and with the limited human resource to undertake awareness creation and service delivery concurrently, modifying the application to allow the general population to self-assess will scale not only the hospital visits but will address refractive error-Opinion leader#03 Integrate into an existing healthcare facility for utilizationLimited difference between a mounted visual acuity and the application Integrate telereferral to allow trained community members to refer patients for comprehensive examination Design to allow the general population to self-assess and telerefer to a nearby vision centreVol.:(0123456789)Scientific Reports | (2024) 14:3750 | https://doi.org/10.1038/s41598-024-54493-zwww.nature.com/scientificreports/

Table 9 .
Strengths and weaknesses of the hub and spoke model.

Table 10 .
Opportunities and threats of the hub and spoke model.

Table 11 .
Proposed recruitment assessment guideline for training primary vision technicians.

Table 12 .
Strengths and weaknesses of the operation eyesight universal.

Table 13 .
Opportunities and threats of the operation eyesight universal.

Table 17 .
Opportunities and threats of the DOT glasses.Introduce subsidized spectacles within the established eye units and integrate the trained individuals to the established eye units • Questions around the credibility of the trained personnel's • Equip a public or private health facility in areas with dire need of RE services and introduce subsidized spectacles • Limited from achieving the 2030 in SIGHT as only presbyopia is being addressed • Integrate telemedicine to ensure that the middle level healthcare professionals trained can deliver RE services under supervision of an optometrist • Integrate mHealth applications such as the Peek Acuity to scale screening activities • The model can be linked with the KSB model which undertakes comprehensive RE management Vol:.(1234567890) Scientific Reports | (2024) 14:3750 | https://doi.org/10.1038/s41598-024-54493-z